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New Hampshire Opioid Prescribing Resource

for Chronic Non-Terminal Pain

Developed by the New Hampshire Medical Society (NHMS) Task Force on Pain and Prescription Opioid Misuse

This resource focuses on the treatment of chronic non-terminal pain; however, clinicians may also find the principles, tools and other cited resources helpful for the management of acute pain and pain associated with terminal illness.

Evidence is evolving related to the best practices in opioid therapy of chronic pain. This resource guide is a product of a clinical consensus process with integration of available evidence by a task force of the New Hampshire Medical Society*. It draws on the 2009 American Pain Society/American Academy of Pain Medicine Guidelines on the Use of Opioids in the Treatment of Chronic Pain.

The resource is offered with the understanding that appropriate medical practice must be determined in a specific clinical context, based on clinical options reasonably available and the judgment of the clinician and the preferences of the patient.

NHMS provides links for informational purposes, but cannot assure the quality of services or accuracy or scientific validity of information provided by the link; judgment and care are advised in using the linked content. We would appreciate feedback on broken, inaccurate or unhelpful links and suggestions for alternatives or additions. Contact mary.west@nhms.org.

1. Position of Opioids in Treatment of Chronic Non Terminal Pain (CNTP)

a. Chronic non-terminal pain reflects a diverse set of conditions. A chronic disease model of treatment that engages the patient in an active management role is often important to care.

b. CNTP often benefits from multidimensional treatment that addresses physical, psycho-spiritual and social dimensions of pain. Often combinations of exercise, physical modalities, psychobehavioral interventions, interventionist treatments and non-opioid medications may provide satisfactory treatment.

c. A trial of chronic opioid therapy (COT) may be appropriate for moderate or severe CNTP that is having an adverse impact on function or quality of life, when potential therapeutic benefits are likely to outweigh potential harms, and when other interventions are unsuccessful, not reasonable, or present greater risk to the patient.

2. Patient selection and risk stratification

a. Prior to initiating COT for CNTP, or when accepting a patient in transfer on COT, or when it becomes clear that acute pain treatment is transitioning into COT of more persistent pain, documentation of pain history, pain treatment history, physical examination, appropriate testing, and a working hypothesis of the etiology of the pain and any co-occurring factors that may affect pain and pain treatment will provide a solid foundation for care. Evaluation-pain (limited to pain).pdf and EvaluationChronicPain-Initial(UMich).pdf

i. If opioid prescribing is transitioned to an addiction specialist, psychiatrist, other mental health-oriented professional or to a temporarily covering physician, working in collaboration with a PCP, pain specialist or other clinician who periodically examines the patient with respect to pain, omission of physical examination by the actual prescriber may be appropriate.

c. Assessment of potential risk of opioid misuse either by clinical interview or using a validated risk screening tool can inform development of a plan for clinical care that appropriately accommodates identified risk. Opioid risk screening tools and articles

d. Urine toxicology screening provides objective information on substance use and can be a valuable source of information prior to initiation of long-term opioid therapy, when acute pain appears to be becoming chronic, or when accepting a patient in transfer who is already using opioids. Information on urine toxicology screening

e. Higher risk patients. Management of patients identified as at higher risk for opioid misuse demands more intensive and structured management to assure patient and public safety. Consultation with, referral to, and/or co-management with a mental health, addiction or pain specialist for higher risk patients is often appropriate.

f. Pregnancy. Women of childbearing potential need to understand the relative risks and benefits of COT during pregnancy and after delivery. Minimal or no use of COT for pain during pregnancy is usually advised, unless potential benefits clearly outweigh risks. If COT is used during pregnancy, it is important to anticipate and accommodate risks to the patient and newborn. NH high risk OB Centers and info on pain management in pregnancy

a. Discussion of the potential risks and benefits of opioid therapy supports informed decision-making by the patient. A written and signed informed consent provides documentation of understanding and acceptance of potential risks and benefits by the patient. Examples of opioid informed consent & agreement

b. Treatment agreements for opioid therapy of pain often include: goals of treatment, responsibilities of the patient and provider in the care plan, conditions for continuation and discontinuation of treatment, and counseling on safe storage and disposal of unused medications. A written and signed treatment agreement provides documentation of the plan of care. Examples of opioid informed consent and agreement

d. It is often helpful if members of the treatment team who are longitudinally involved in care of the patient, including the patient, primary care provider office, co-managing specialists, pharmacist, and others, have a copy of the agreement

4. Initiation, titration and revision of COT

a. Initial treatment with opioids may be considered a therapeutic trial that can be continued or stopped depending on the response to treatment.

c. Opioid rotation (changing from one opioid to another) may be helpful when a patient on COT experiences intolerable adverse effects or inadequate benefit despite dose increases in the absence of progressive pathology. Opioid comparison chart and opioid rotation information

d. Higher doses of opioids may be associated with greater risk of opioid induced hyperalgesia (OIH), endocrine side effects, opioid overdose, diversion and other adverse consequences. Patients on greater than 120-200mg morphine equivalents per day are often viewed as higher risk patients and may benefit from increased monitoring to assure that opioids are helping more than hurting. Opioid rotation may be helpful to avoid higher doses. Opioid comparison chart and opioid rotation information

e. Methadone is characterized by complicated and variable pharmacokinetics and pharmacodynamics as well as significant drug-drug interactions and potential for important changes in QT interval. Methadone should be initiated and titrated with care by clinicians who have familiarized themselves with its proper use and risks. Some professional groups recommend baseline EKG and periodic reevaluation or routine EKG above a specific dose level and with dose changes. Guidelines are evolving. Methadone in pain treatment

5. Monitoring

a. Patients on COT benefit from reassessment on a regular basis and as warranted by changing circumstances. One to three month reassessment is most commonly appropriate; more often may be indicated in some patients; and less frequently may be reasonable only when medical, psychosocial and contextual stability is clear.

c. Urine toxicology screening may provide objective information regarding medication use and/or use of non-prescribed substances. Many experts recommend baseline and at minimum annual random screens for all patients, regardless of identified risk group, more often for higher risk patients or when concerns arise. Confirmation studies (usually GCMS studies) of unexpected screening findings (usually immunoassays) are necessary to more accurately define findings. Knowledge of laboratory test inclusions and cut-offs as well as appropriate interpretation is critical and often benefits from discussion with a toxicologist. Information on urine toxicology screening

d. Identification and treatment of common opioid-associated adverse effects can improve outcomes.

e. Patients may engage in aberrant opioid-related behaviors for diverse reasons. Assessment for co-occurring conditions (psychiatric, addictive or other), referral for assistance in management, restructuring of care to support safety, and/or consideration of COT discontinuation if behaviors persist or are life threatening, may improve outcomes. Tracking aberrant behaviors and structuring care in higher risk patients

f. Consultation, including interdisciplinary pain management, may improve outcomes in complex patients with CNTP who may benefit from additional skills or resources that the prescriber cannot provide. New Hampshire pain treatment providers and consultation resources

iii. if there are significant or persistent violations of the opioid agreement plan that do not resolve with restructuring or intensification of care;

iv. if opioid diversion, script tampering or other illicit behavior is identified

v. If the patient wishes to discontinue opioids

b. Physically dependent patients usually require opioid taper to avoid withdrawal when longterm opioids are discontinued. Patients with addiction or other pathologies may require exogenous controls on opioids while tapering to maintain safety or facilitate gradual taper. Opioid discontinuation

c. If opioid misuse is related to a substance use disorder, mental health disorder or other medical problem, patients may benefit from appropriate specialty care while alternative non-opioid treatments for pain provided as indicated.

7. Team Management

a. A primary care medical home (PCMH) can improve care by facilitating care coordination and communication among all clinicians involved in the patient’s care. A designated care coordinator and a clinical registry are evolving practices that may improve care. The PCMH may or may not be the prescriber of opioids.

b. Patient care is improved when specialists who participate in pain care and/or who prescribe COT communicate regularly with the PCMH, particularly when changes in management occur.

8. Legal Issues

a. Clinicians should be aware of current federal and state laws, regulatory guidelines, and policy statements that govern the medical use of COT for CNTP. New Hampshire and Federal policies

b. Certain actions by patients may be in violation of the NH Controlled Drug Act: RSA 318 B:2. Criminal behavior such as prescription forgery, prescription theft, or diversion of opioid medication for sale may render the therapeutic relationship between clinician and patient void and because such behavior threatens public safety, it is a serious medical concern. If such behaviors are confirmed or strongly suspected the clinician should consider notification of law enforcement. Consultation with your risk or legal advisor is appropriate.

c. Sometimes patients may become disruptive, abusive or violent in the context of clinical encounters around opioids. Private and voluntary medical offices and facilities have the right to exercise discretion in determining whether a particular patient warrants non-emergent outpatient and/or inpatient care or admission and therefore, abusive and/or inappropriate behavior by a patient does not need to be tolerated. Security and law enforcement should be contacted when the safety of staff or patients is threatened.

9. Care System and other Opioid Policies

a. It is important for providers be aware of and honor policies within their own systems of care which may be more proscriptive than this resource.

This resource reflects the contributions of diverse healthcare providers who participated on the NHMS Task Force on Pain and Prescription Drug Misuse in a variety of ways, large and small. Contributors to date include: